BUSINESS CONTINUITY PLAN

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1 BUSINESS CONTINUITY PLAN FOR QUEENSLAND HEALTH CENTRAL STERILIZING DEPARTMENT EXAMPLE HOSPITAL

2 TITLE This plan shall be titled and known as the: BUSINESS CONTINUITY PLAN FOR QUEENSLAND HEALTH CENTRAL STERILIZING DEPARTMENT, EXAMPLE HOSPITAL AUTHORISATION The Plan provides the mechanism for restoring core essential services should an unplanned interruption occur causing a loss of capacity in Central Sterilizing Departments. The Plan can also provide guidance in preparing for a planned closure of all or part of the Central Sterilizing Departments capacity. This plan only applies to Queensland Health central Sterilizing Departments. APPROVED BY: DIRECTOR NAME Executive Director Director of Medical Services, EXAMPLE Hospital EXAMPLE Hospital and Health Service Date: PRINTED COPIES ARE UNCONTROLLED 2

3 Table of Contents Abbreviations...4 Instructions...4 Authority and Planning Responsibility Introduction - Plan Overview...6 Purpose...6 Scope...6 Framework....6 Rationale Pre-Issue Planning Essential Functions, Activities and Minimum Resources...7 Essential Functions...1 Table 1 Identification of Essential Business Functions...7 Table 2 Business Impact Analysis...9 Table 2a Impact Ratings...1 Minimum Resource Requirements...10 Table 3 Essential Equipment per function list...10 Table 4 Minimum Staffing Requirements...12 Management of absenteeism...13 Table 5 Staff Category Ratings Continuity Plan...14 Table 6 - Determining Responsibilities and Operational Activities...14 Operational Checklist...15 Activation...15 Service Agreements / Memorandums of Understanding...15 Alternative Work Arrangements...15 Table 7: Alternative Facilities...16 Additional Assistance...17 Returning to Normal Operational Mode Maintenance and Testing of Plan...18 Maintenance of Plan...18 Testing of Plan Appendices...20 Appendix 1a Activity Summary: flow chart...20 Appendix 1b Activities to be Undertaken...21 Appendix 1c Operational Checklist...22 Appendix 1d Business Impact Assessment:...23 Appendix 2 Staff Contact List, Category Rating & Special Skills...24 Appendix 3a Reporting Template...25 Appendix 3b TRANSIT Log...26 Appendix 4 Essential Contact Log...26 Appendix 5 - Communication Guidance...29 Appendix 6a Service Agreement Answers about Your Facility...30 Appendix 6b Service Agreement Questions about other Facilities...31 Appendix 7 Testing of plan...32 Appendix 8 Service Agreement / Memorandum of Understanding with Appendix 9 Service Agreement / Memorandum of Understanding with Appendix 10 Service Agreement / Memorandum of Understanding with Resources...34 PRINTED COPIES ARE UNCONTROLLED 3

4 Abbreviations BCP BIA CDB CHRISP CHO CSD CEO DON DTPM FTE HPID HHS HSPL MI NUM SA SOP SUO Business Continuity Plan Business Impact Analysis Communicable Diseases Branch Centre for Healthcare Related Infection Surveillance and Prevention Chief Health Officer Central Sterilizing Department Chief Executive Officer (of HHS) Directors of Nursing Desktop Procedure Manual Full Time Equivalent Health Planning and Infrastructure Division Hospital and Health Service Health Services Purchasing and logistics Medical Industry Nurse Unit Manager Service Agreement Standard Operating Procedures Single Use Only Instructions Yellow text boxes & highlights in this example are guides only. Grey shaded text in the electronic templates are form fields to fill in with your own details as required (these will not print out shaded). All tables are filled out with sample information from a trial site as an example only. Any tables with some information filled out in the templates are also example information only as a guide for completion. You should pay careful attention to ensuring you complete all tables with requirements specific to your facility and Hospital & Health Service. This example may not be complete and is intended as an example only. The CSD BCP planning template is where it is intended for full information to be completed for all BCP requirements. The CSD BCP functional template should have information transferred across from the planning template for ease of use if a disruption should occur. Any names used in examples are for example purposes only and any correlation to actual Queensland Health staff or other people is purely coincidental. PRINTED COPIES ARE UNCONTROLLED 4

5 Authority and Planning Responsibility The development, implementation and revision of this Plan are the responsibility of the Hospital & Health Service Chief Executive Officer (CEO) or nominated delegate. Amendments to this plan need to undertake a formal approval process through the CEO or delegate. To ensure accessibility to the Business Continuity Plan (BCP), it is required to be saved electronically on a network drive accessible by Central Sterilizing Department (CSD) Nurse Unit Managers (NUM) and Operating Theatre, saved electronically as a back up on an external hard drive or similar as well as printed hard copies in essential areas as deemed necessary by the CEO or delegate. Amendment List Amendment Number Amendment Date Sections Amended /1/2012 Final Example document to assist with completing the template Amended By CHRISP PRINTED COPIES ARE UNCONTROLLED 5

6 1. Introduction - Plan Overview Purpose The purpose of this BCP is to detail the key people/positions and the responses and actions needed to enable Queensland Health (QH) Central Sterilizing Departments (CSD s) to continue essential functions in the event of a service disruption. All CSD staff should familiarise themselves with this plan and the role(s) they may be expected to assume during a service disruption. Scope BCP s should be reasonable, practical and achievable. This BCP focuses on consequences from disruption to CSD. It is not concerned with the likelihood or cause of occurrence, as they are not elements of the BCP. This BCP makes no attempt to cover any situation other than those that impact directly on CSD and their ability to meet the core objective of providing the necessary services for reprocessing of re-usable surgical instruments and equipment. This BCP is intended only for use by CSD and facilities that rely on CSD for reprocessing of instruments & equipment. Framework Queensland Health operates under an Emergency Preparedness and Continuity Management Policy and Framework. This BCP is recommended to be adopted as a sub-plan of the Business Continuity Plan of the Individual Hospital & Health Services and facilities requiring CSD and to complement the overall Queensland Health Emergency Preparedness and Continuity Management Policy. Rationale Implementing this BCP is a reactive process where the careful assessment of the type and severity of the service disruption will determine the necessary actions. It is not possible or practicable to develop detailed recovery plans for every possible incident type. This recovery plan focuses on a systemic approach to business continuity while seeking to minimise confusion over roles and responsibilities within QH CSD. PRINTED COPIES ARE UNCONTROLLED 6

7 2. Pre-Issue Planning Essential Functions, Activities and Minimum Resources Essential Functions As each Hospital & Health Service & facility have different capabilities, urgency for continuation of services, and opportunities for contingencies, it is impossible to develop a standard Essential Business Function table. A table is provided below as a guideline. The table lists, as an example, the essential functions specific to a facility, skills & equipment required, maximum acceptable outage (how long can the business continue without this service), priority of getting it back on-line & other relevant comments Table 1 Identification of Essential Business Functions Essential Business Function or Process E.g. Reprocessing of reusable surgical instruments and equipment. (Standard Sets. These are mostly basic items with several in stock like Major trays and also include items for Community services.) Skills Required Equipment Required *Maximum Acceptable Outage Working knowledge of sterilizing equipment. *Priority Comments Manual washing chemicals 2 days 2 Hand washing is backup if washers go down; may need more staff Mechanical washing chemicals 2 days 1 Can fall back to manual but more staff needed Mechanical washers 1 day 1 Can fall back to manual but more staff needed Ultrasonic 2-4 days 3 Only have one; main impact is orthopaedics. Drying cabinets - instruments 2 day 2 Have x 3 of this type Drying cabinets anaesthetic 1 day 1 Only have one of this Packaging materials 1 day 1 Alternatives not always available Heat sealer 1 day 2 Have two tho one is smaller Pre Vac sterilisers 1hr - 2 days 1 Depends on both how many are working on the day and our workload on the day Sterrad Sterilisers for heat sensitive items 1 day 1 Have x2 but even that may not be enough on the day PRINTED COPIES ARE UNCONTROLLED 7

8 Essential Business Function or Process E.g. Reprocessing of reusable surgical instruments and equipment. (Specialist Instrumentation defined as all other instrumentation whether trays or single items of small inventory and including items that may be needed in emergencies) Skills Required Equipment Required *Maximum Acceptable Outage Working knowledge of sterilizing equipment. Knowledge of cleaning of complex instruments *Priority Comments Manual washing chemicals 1 day 1 Impacts on Ortho; is backup if washers go down Mechanical washing chemicals 2 days 1 Can fall back to manual but more staff needed Mechanical washers 1 day 1 Can fall back to manual but more staff needed Ultrasonic 2 days 1 Impacts on Ortho. Drying cabinets - instruments 2 days if partial 2 Have x 3 1 day if none 1 Drying cabinets - anaesthetic 1 day 1 Only have one Packaging materials including tapes 1 day 1 May go up a size in paper; not down; can t seal without tape Heat sealer 1 day 2 Have two tho one is smaller Pre Vac sterilisers Sterrad Sterilisers for heat sensitive items like bronchoscopes 1hr if none 2 days if >50% 1 Depends on both how many are working on the day and our workload on the day 1 day 1 Have x2 but even that may not be enough on the day Maximum Acceptable Outage is taken from table 2 (Business Impact Analysis) and used to determine above Priorities. PRINTED COPIES ARE UNCONTROLLED 8

9 Table 2 Business Impact Analysis This considers the Essential Business Functions required to continue CSD services and rate the impact over the period of time using Table 2a Impact Ratings table below. E.g. if an Essential function was to be out between 2-7 days, would it be considered 4-Major, or 5-Catastrophic. & is the maximum acceptable outage when the rating gets to moderate, or major? Utilise Appendix 1: Business Impact Analysis questionnaire for further guidance. Note: Depending on the combination of variables, the NUM CSD may alter the Impact Rating and the time at which it occurs. Impacts (Rate 1 to 5) Essential Business Function e.g Reprocessing of reusable surgical instruments and equipment. (standard sets) e.g. Reprocessing of reusable surgical instruments and equipment. (specialist procedures) 1-4 Hours 1 Day Days Weeks 2-4 Weeks > 1 month Highest Impact (Provide a description of the highest rated impact) Depending whether outage is partial or total, use of other facilities would be needed. Depending whether outage is partial or total, use of other facilities would be needed. MAO (Maximum Acceptable Outage) 2 Days; may be less depending on scenario as in Table 1. 1 Days/12 hours? Internal short term work arounds (to consider if always available to reduce impact rating) *Implementation of a 24 hr service that we don t now have. *Additional staff to hand wash. *Borrow Oral Health bench top sterilisers. *Implementation of a 24 hr service that we don t now have. *Additional staff to hand wash.. Comments Many variables need to be considered e.g. if no sterilisers were available, we would go to contingency by 4 hours. If the problem were with washers, the impact would not be felt until more time lapsed. Many variables need to be considered e.g. if no sterilisers were available, we would go to contingency by 4 hours. If the problem were with washers, the impact would not be felt until more time lapsed. PRINTED COPIES ARE UNCONTROLLED 9

10 Table 2a Impact Ratings You will need to define what these categories mean in collaboration with NUM Perioprative in relation to Surgical Services Rating Category Description 1 Insignificant No measurable operational impact to the business. 2 Minor Minor degradation of operations or service delivery. 3 Moderate Substantial degradation of operations or service delivery. 4 Major Significant degradation of operations or service delivery. 5 Catastrophic Widespread and total degradation of operations or service delivery. Minimum Resource Requirements The minimum resource requirements for each task include equipment, consumable and human resources. When considering human resources, it may be advisable to not only consider the number of staff required, but also the category of the staff required. (from Table 5). Table 3 Essential Equipment per function list Essential Function or Process Rinse/Wash Equipment Required Double Sinks Validated Washer Disinfectors including one with Anaesthetic capability and all with Printouts Leak Tester Infrastructure (power, water, etc.) Reverse Osmosis Water Town water Power Air gun Water gun Air conditioning 18-22C Write Up area Other (consumables, etc.) Personal protective equipment Lint free cloths Chemicals Soil removal tests Blue food dye Cleaning brushes Clean cotton drapes Linen skip Waste bin Ultrasonic Bench top type Town water Power Air conditioning Chemicals Test equipment PRINTED COPIES ARE UNCONTROLLED 10

11 Dry Wrap/Pack Sterilize Instruments Drying cabinets including one for Anaesthetic s Trolleys Wrapping tables, preferably height adjustable Heat sealer Magnifying Light Electrosurgical insulation tester Computer and printer Loading trolleys Write up area May need closed trolleys for transport externally. Power Cool down Trolleys Air conditioning 18-22C Sterile Storage Dedicated area as per AS4187 Air conditioning 18-22C Clean cotton drapes or towels Air conditioning 18-22C Wrapper, sterilisation synthetic sizes 45 x 45 to 137 x 137 Tape seal sterilisation with chemical indicator (steam) Tape seal sterilisation with chemical indicator (Sterrad) Manual tracking system labels (steam) Manual tracking system labels (Sterrad) Tip protectors White textile (cotton) tape 6mm Permanent marking pens as per AS4187 Autoclavable tray liners Plastic bags Oxygen tubing Plastic sleeves for tray checklists Water + power (steam) Log sheets Transit Forms Loan Sets As for Wrap / Pack Write up Area As for Wrap / Pack Stationery PRINTED COPIES ARE UNCONTROLLED 11

12 Table 4 Minimum Staffing Requirements All facilities have differing standard operating hours & staffing needs. The Current Resource figures below represent the normal numbers of staff rostered in CSD at trial hospital. The Resource Requirements below helps to guide the numbers of additional staff that may be needed. The resource requirements may vary significantly depending on the amount of service capacity remaining and whether outsourcing to multiple sites and / or implementing a temporary night duty shift. Essential Business Functions Current Resource Level (available to complete key business process) Additional Resource Requirements. Minimum additional levels required to complete key business processes (we need to consider that we may require additional resources in some instances. e.g if functions being performed off-site or alternate location within the facility or if a Night Duty shift needs to be implemented where it is not normally worked.) Manual Alternate Workarounds (Yes/ No) Reprocessing of reusable surgical instruments and equipment standard and specialist) AM PM W end <1 hour 1-4 hours 1 Day 2 to 7 Days 1-2 Weeks 2-4 Weeks > 1 Month Yes (single use only; see table 1) PRINTED COPIES ARE UNCONTROLLED 12

13 Management of absenteeism While minimum staffing levels are factored into the Business Impact Analysis and are listed in the Minimum Staffing Requirement section, management of absenteeism becomes an issue in itself in the context of prolonged leave or absence. Proper management of absenteeism will allow the Hospital & Health Services to continue to deliver essential services even in the face of increased and prolong absences of staff. To help determine appropriate placement of staff, the following categories have been developed. Consideration also needs to be given to the fact that additional staff on top of normal operating levels may well be required upon activation of the BCP due to the break of the usual workflow making it difficult for staff to move between stations and cover multiple areas. Table 5 Staff Category Ratings This table is internal use only, please amend definitions to suit as required. Staff Category Category 1 (NUM CSD) Category 2 (2 nd in charge CSD) Category 3 (Normal Staff) Category 4 (Other facility staff with transferable skills) Category 5 (As with Category 4 that may be released to alternate sites) Definition Personnel who perform an essential function that must be maintained within Sterilizing Services. Personnel who can be used as secondary support for Category 1 staff due to multi skilling / cross training. Personnel who perform an essential function and where such a function can continue to be effectively provided from a remote location e.g. another facility with which a MOU may be in place and activated. Personnel whose work cannot be done from another facility but can be deferred for a period of time e.g. minimum requirements can be achieved by 2-3 days per fortnight. May be resource shared on limited basis within the facility. Personnel with deferred functions available for redeployment from within the facility / Health Hospital Service. Refer to Appendix 2 Staff Contact List, Category Rating & Special Skills PRINTED COPIES ARE UNCONTROLLED 13

14 3. Continuity Plan Table 6 - Determining Responsibilities and Operational Activities The following table outlines the key functional areas and who has responsibility for those areas. Functional Areas Position Alternate or Standby Key Responsibility/Activity Activation of BCP DON Your Hospital *NUM CSD Initiate contact with key stakeholders to *Nursing Director determine level of Surgical activation (appendix 5 & 3) Contact key BCP Nurse Unit Manager, Central Sterilizing Department Your Hospital *NUM Operating Theatre *Nursing Director Surgical *Engineering Manager *Hospital Co-ordinator Make contact with key stakeholders from Appendix 5 & proceed as directed in Appendix 3 to facilitate smooth activation of CSD BCP Reports to ED Your Hospital DON Your Hospital Contact Central Sterilizing Department Staff Nurse Unit Manager, Central Sterilizing Department Hospital Coordinator Contact staff to advise of alternative work arrangements DON Your Hospital Return to normal operation Nurse Unit Manager, Central Sterilizing Department *Engineering Manager; *DON local facility; *Sterilizing Program Manager CHRISP *CSD Shift Supervisor (only if < 4 hours) Assess functionality & capability of CSD as being able to perform essential functions & notify key stakeholders (appendix 3) of return to normal. ED Your Hospital PRINTED COPIES ARE UNCONTROLLED 14

15 Operational Checklist The following resources have been developed to ensure all required tasks are documented so that the essential functions of CSD BCP are maintained: Appendix 1a BCP activation flow chart Appendix 1b Activities to be Undertaken Appendix 1c Operational Checklist Activation The decision to activate this plan independently of the BCP of the Local facility is the responsibility of the DON. Once this decision has been made, the NUM CSD will notify the key stakeholders in Appendix 4 and utilise Appendix 5 Communication Guidance in contacting the relevant stakeholders. Activation of the BCP of the local facility may not always necessitate the activation of the CSD BCP. Activation of the local facility BCP may in fact negate the CSD BCP, or alternatively rely on parts or all of the CSD BCP. Service Agreements / Memorandums of Understanding As outsourcing of CSD is anticipated to be a major part of the continuity of CSD, a Service Agreement (SA) or Memorandum of Understanding (MOU) between parties may be needed. For assistance in establishing a MOU or SA with other facilities, contact your local Contract Hub for assistance. Refer to QHEPS site: If a MOU or SA is created, a brief summary of each should be recorded as an Appendix. A list of some suggested questions to ask when setting up such agreements is located in appendix 6 Service Agreement questionnaire. Alternative Work Arrangements There are a number of options to consider when alternative work arrangements and the relocation of essential functions are required. It is the responsibility of the NUM CSDs, to determine the best option at the time of disruption. The options available may include but are not limited to: Relocating to another section within same building; (is there another room that may be utilised as: initial wash/remove gross debris, clean area for wrap/pack, sterile storage (unutilised theatre), Oral Health Bench Top Sterilizers) Relocating to alternate facilities as arranged in the MOU or SA (if any) & outlined in Table 7. PRINTED COPIES ARE UNCONTROLLED 15

16 Table 7: Alternative Facilities (examples only) Alternate Location or Facility Private Facility 1 Private Facility 2 Tasks able to be undertaken at this location Cleaning and sterilizing standard and some special instruments Cleaning and sterilizing standard and some special instruments Capacity to accept % of normal load (full service) Ability to reprocess complex sets: (list specialities) % General and Orthopaedics; may need to send our staff % General and Orthopaedics; may need to send our staff QH facility within Hospital & Health Service 1 QH facility within Hospital & Health Service 2 QH facility within Hospital & Health Service 3 QH facility outside Hospital & Health Service 1 Oral Health dedicated CSD Oral Health Clinics Other (dept. of Defence?) All tasks % All specialties with our staff All tasks % All specialties with our staff All tasks % All specialties with our staff All tasks % All specialties with our staff Cleaning and sterilising standard instruments Consider borrowing bench top sterilisers and having them brought to Redcliffe CSD % Standard and some special items with our staff; Dental staff may need to be arranged to support us. % Our staff working here All tasks % All specialties with our staff Please refer to the MOU or SA (if any) for Hours of Operation, and Staffing Requirements for each facility above. PRINTED COPIES ARE UNCONTROLLED 16

17 Additional Assistance Appendix 4 outlines a list of key stakeholders who will provide additional assistance to influence CSD BCP. A key requirement for additional assistance may be transport providers. Supply Services logistics managers may be of assistance, as well as engaging external freight management/transportation companies. We will need to ensure that this complies with AS/NZS 4187:2003 sections 2.3, 2.4, & 9.4 as well as referring to Easi-Sterilise Standard Operating Procedures 1.2 & 4.3 When making arrangements to out-source, consider logistical factors like loading dock heights relative to the trucks, access to these and / or to the other facility. Ask questions like Do Security need to open gates? Returning to Normal Operational Mode The NUM CSD/Nursing Director Surgical Services will keep all team members updated and advise when return to normal operating mode. Remedial action will be completed as required to integrate work completed during the continuity operating mode. The NUM CSD/Nursing Director Surgical Services shall notify all clients\other departments of the return to normal business operations. The Nursing Director Surgical Services is responsible for timely debriefing sessions with staff. Lessons learned should be used to update BCP. Appendix 1c Operational Checklist includes checks for returning to normal operational mode. PRINTED COPIES ARE UNCONTROLLED 17

18 4. Maintenance and Testing of Plan Maintenance of Plan All files associated with this plan can be found in: Electronic: Local network drive (accessible by all key stakeholders) USB portable drive (kept in accessible location for all key stakeholders) Hard Copy: Education Room CSD NUM Office CSD Hospital Co-ordinator Office Amend Hard Copy & Electronic copy locations to suit your specific needs & governance structure The CHRISP base templates and example will be saved at: When the plan is tested and/or revised or any of the tables, appendices and/or content of this BCP is updated, it is important to save a copy of these files not only to the designated directory but also save them to the external source and reprint/amend the hard copy. If minor amendments only are required, there may be no need to re-print the hard copy of the document, just simply cross out & change as required, initial & date the changes. Testing of Plan Responsibility for testing the plan rests with both the NUM CSD and the Nursing Director Surgical Services. Testing of the plan does not require full physical activation, but a table top activation consisting primarily of the communication requirements such as contacting Management, Engineering, NUMs of other facilities, Transport providers, and CSD staff to ensure readiness without actually actioning the BCP. The testing of the plan should not only simulate a loss of capacity in functionality of CSD hardware resources, but also with a loss of people in critical positions. This will confirm the BCP is functional / usable for all staff that may be required to use it. Start the conversation for testing the plan with the following: This is a theoretical simulation of the EXAMPLE Hospital CSD BCP The BCP Plan should be tested at the following timelines and recorded in Appendix 7 Testing of Plan: o following initial completion of the plan; o following any major revisions of the plan; and o bi-annually. PRINTED COPIES ARE UNCONTROLLED 18

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20 Appendices for Business Continuity Plan for Queensland Health Sterilizing Services 5. Appendices Appendix 1a Activity Summary: flow chart PRINTED COPIES ARE UNCONTROLLED 20

21 Appendices for Business Continuity Plan for Queensland Health Sterilizing Services Appendix 1b Activities to be Undertaken 1. Identification of Fault/Disruption (Document the entire process as it unfolds to make writing a report at the end easier & ensure all information is captured to be able to review the BCP, SA s & MOU s) a. Notify Engineering to ascertain cause & determine possible length of disruption b. Notify Nursing Director Surgical & Nurse Unit Manager Operating Theatre. (keep notifications current as more information comes to hand in steps below) c. Notify CHRISP (keep notifications current as more information comes to hand in steps below) 2. Determine if disruption will exceed maximum acceptable outage as determined in Tables 1 & 6 3. Determine if Activation of SA s/mou s is required & to what extent (is it a washer only that is out of service, sterilizer only etc. & what % of capacity is required to be sent off-site); a. Yes contact CSD NUM s of the facilities you have set SA/MOU s with b. Yes Contact your staff to inform of alternative work arrangements c. Yes Contact other service providers for transportation needs d. No Inform key stakeholders (Nursing Director Surgical, Nurse Unit Manager Operating Theatre, CHRISP, etc.) as to what capacity the CSD can operate at, and when CSD is predicted to be back to 100% functionality. 4. Monitor the effectiveness of SA/MOU s & other works being undertaken to provide continuity of essential functions. 5. Once CSD is operational to resume all essential functions, cease SA/MOU s & inform all key stakeholders a. Report on the event using appendix 4 to DON & CHRISP outlining: i. Issue that caused disruption ii. Barriers to rectifying iii. Barriers to continuity (e.g. any issues activating SA/MOU) iv. Acknowledge what worked well v. Time line of events vi. Conclusion & any recommendations for improvement. PRINTED COPIES ARE UNCONTROLLED 21

22 Appendices for Business Continuity Plan for Queensland Health Sterilizing Services Appendix 1c Operational Checklist Action Reason Done 1. Complete & maintain (ongoing outside/prior to activation of the plan) Tables 1, 2, 3, 4, 6 & 7 To keep plan current Appendix 3 Staff contact, Category Rating & Special Skills To keep plan current Appendix 5 Essential Contact List 2. Contact (upon activation) Appendix 5 Essential Contact List Appendix 2 Staff Contact, Category Rating & Special Skills 3. Recording of Events (During activation of BCP) Document which Service Agreements are being utilised & what portion of work is being carried out at each facility. Maintain a log of inventory out & in, including documentation of processes undertaken at alternate facilities to ensure compliance with standards. Appendix 4a Tracking Log Document agreements/contracts with other external providers such as transport/freight companies Document steps taken to rectify the issue within CSD 4. Resume Essential Functions Inform all Key Stakeholders & Staff that were contacted in step 2 (from Appendix 2 & 5) and cease all SA/MOU with alternate facilities and additional assistance with external stakeholders once CSD is functional to perform essential functions. Report on the entire process from initial issue through activation of BCP to resumption of essential services. (Include comments/reports from facilities assisting). The severity of the issue will determine the detail of the report. Reports to go up the chain within the facility & to CHRISP using template on appendix 4. To keep plan current To determine fault & begin continuity measures To respond to required activation needs (such as alternative work arrangements) To assist with tracking of instruments, accountability of work To assist with tracking of instruments, accountability of work To assist with tracking & accountability of transportation For future reporting needs Alleviate workload of assisting CSD, return to normal and best practice processes. To be able to evaluate and possible improvement on the process to share with all Queensland Health CSD PRINTED COPIES ARE UNCONTROLLED 22

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